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Alopecia UK Birthday Champion Sign Up Form
Full name
Email address
(required)
Please enter your email address
Please enter a valid email address
Confirm email address
(required)
This field is required
Telephone number
(required)
This field is required
Age
(required)
14-16
17-24
25-34
35-44
45-54
55-64
65-74
75 or older
What is your connection to alopecia?
(required)
Please tick a checkbox
I have alopecia (hair loss)
I am supporting a loved one with alopecia
I engage with people who have alopecia through my work
I have no connection to alopecia but have been inspired to get involved
Do have have hair loss? If so what type?
(required)
Please tick a checkbox
Alopecia Areata
Alopecia Totalis
Alopecia Universalis
Androgentic Alopecia (Pattern hair loss)
Frontal Fibrosing Alopecia
Linchen Planopilaris
Telogen Effluvium
Traction Alopecia
Chemotherapy Induced Alopecia (Anagen Effluvium)
Other
I do not have hair loss (alopecia)
Ethnicity
(required)
White - English/Welsh/Scottish/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveller
Any other White background
Mixed ethnic background - White and Black Caribbean
Mixed ethnic background - White and Black African
Mixed ethnic background - White and Asian
Mixed ethnic background - Any other mixed or multiple ethnic background)
Asian/Asian UK - Indian
Asian/Asian UK - Pakistani
Asian/Asian UK - Bangladeshi
Asian/Asian UK - Chinese
Asian/Asian UK - Any other Asian background
Black/ African/Caribbean/Black British - African
Black/ African/Caribbean/Black British - Caribbean
Black/ African/Caribbean/Black British - Any other Black/African/Caribbean background
Other ethnic group - Arab
Other ethnic group - Any other ethnic group
To which gender do you most identify?
Male
Female
Gender non-conforming
Prefer not to say
Would you like an Alopecia UK T-shirt?
(required)
Yes
No
If YES, please give your FULL address including POSTCODE. (We cannot send out t-shirts without your address!)
If YES please also select your size (Subject to availability! To keep our costs to a minimum, we kindly ask if you already have an AUK t-shirt that you use that in your fundraising)
No t-shirt needed
Adult Small
Adult Medium
Adult Large
Adult X Large
Adult XX Large
Child Age 3-4 Years
Child Age 5-6 Years
Child Age 7-8 Years
Child Age 9-11 Years
Child Age 12-14 years
Would you like to join the 2020 AUK Birthday Champions Facebook Group?
(required)
Yes
No
If YES, please provide the email address associated with your Facebook account as the invite will get sent to that. (The group will only be active for August and September)
Are you happy for your ‘public’ social media content (picture and wording) to be shared by Alopecia UK: (Please select all that apply)
(required)
Please tick a checkbox
On our Facebook Page with your first name only
On Twitter as a retweet
On Instagram including your handle
Collated (anonymously) into a video and shared on all of the above as well as YouTube
Are you interested in participating in any media? (e.g. newspaper and magazine articles both in print and online, TV and radio)
(required)
Yes
No
If yes, please tell us a bit about your alopecia story or relationship to alopecia in no more than 150 words. Make it as interesting as you can as it will be this information we pass on to journalists who may be looking for individuals to take part in st
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